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PATHWAYS FOR YOUNG LEADERS REGISTRATION APPLICATION SEPTEMBER 2019 – MAY 2020
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APPLICANTS FIRST NAME
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LAST NAME
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APPLICANTS D.O.B.
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AGE
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GRADE
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PARENT/GUARDIAN
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STREET ADDRESS
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APT #
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CITY
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STATE
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ZIP CODE
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PARENT/GUARDIAN CELL#
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EMAIL ADDRESS
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DOES CHILD HAVE ANY FOOD ALLERGIES
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IS CHILD IN GOOD HEALTH
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TAKING ANY PRESCRIBED MEDS
Yes
No
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IF YES PLEASE LIST ALL MEDICATIONS
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EMERGENCY CONTACT NAME
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EMERGENCY CONTACT CELL #
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CHILD HAS PERMISSION TO WALK HOME ALONE AT 5:30 PM DISMISSAL
Yes
No
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